Craft - a meditation

Introduction

Physicians have many names, internist, surgeon; names that we may not be enamored of, provider, employee; and names we might cherish, Doc, or healer. But there is one name, a characterization really, that we all acknowledge and admire, professional. But what exactly does that term mean? This musing began as an attempt to understand how historically we ‘became professionals,’ what that requires of us and how it possibly will change in our digital age. As I read more deeply, I recognized two conversations going on at once. There is an inner facing dialogue about how we approach our work; it’s unique qualities, concerns, and sticking points. We are, in reality, craftsmen and we forsake this identity, as makers, at some risk to our inner self. The Craftsmen by Richard Sennett is my inspiration and provides an intellectual path in this contemplation. The second conversation is seen in the organization of our craft, how we interact with society, it is our outward face. It is the origin of our ‘professionalism’ as an expression of our craftsmanship. For insight into this process, I have delved into Richard and Daniel Susskind’s The Future of the Professions. Finally, in my attempt to rejoin mind and body, particularly in respect to the inner dialogue of the craftsman I have gratefully stolen from Guy Claxton’s Intelligence in the Flesh. Each of these is worth reading; my craft has been to select aspects of their thoughts and recombine them; hopefully, in the words of Austin Kleon, I have “stolen like an artist.”

A quick housekeeping note. Craft is not gendered specific even though craftsman and craftsmanship suggest it. Rather than keep track of the number of male and female references or using the less fluid, craftswomanship, I have stayed with craftsman and craftsmanship – I mean no disrespect. Internal medicine is as much a craft as surgery; I apologize in advance if the preponderance of examples, comes from my craft.

Let us begin in the present and what Richard and Daniel Susskind describe as the “grand bargain.”

The Grand Bargain

“The greatest improvement in the productive powers of labor, and the greatest part of skill, dexterity, and judgment with which it is anywhere directed, or applied, seems to have been the effects of the division of labor.” Adam Smith

Exchanging knowledge for labor and you realize that specialization of knowledge is a significant force in civilization’s growth. But specialization makes it increasing difficult to adequately managing our affairs. We cannot know everything and we are dependent upon other people’s knowledge to navigate in modern society. One of the specialization’s hidden disadvantages is in finding ways to share these understandings in society. This difficulty is particularly the case for medical care, where we, as physicians, have enormously greater knowledge; in fact, even within medicine, each specialist has vastly differing facts at hand. Society’s answer are the professions.

“All professions … are a solution to the same problem – that none of us has sufficient specialized knowledge to cope with all of our daily challenges.” [1]

The Susskinds identify four characteristics of professions.

1) Specialist knowledge – both formal academic knowledge, the explicit information to be found in textbooks, journals and lectures; and implicit knowledge – the practical ability to apply this information to help, in our case, patients. Additionally, as specialists, it is expected that we act as investigators expanding and curating our knowledge sharing this information in service to our patients.

2) Admission to the profession depends on credentials –a third party vouches for their “grasp of the substantive teachings of a discipline”[1] e.g. Boards of medical examiners and specialties. Additionally, peers attest to the character of the newly admitted professional.

3) Activities of professionals are regulated – The states grant professionals “exclusivity over certain activities”[1] In giving such a large degree of autonomy to individual practitioners, to act as they alone see fit, society creates structures for governmental or professional oversight e.g. CMS or the American Boards of Specialties. These oversight structures create not only regulation by credentials but the second regulation with explicit standards of ethical conduct.

4) Professionals are bound by a set of shared values – above and beyond the explicit stipulations of state law, professionals have a duty to act solely on behalf of their client’s interests. The fiduciary responsibilities of an agent to their principal or in our case for a physician to their patient, are codified in law.

The professions have made a ‘grand bargain’ with society based upon these qualities.

"In acknowledgement of and in return for their expertise, experience and judgment, which they are expect to apply in delivering affordable, accessible, up-to-date, reassuring and reliable services, and on the understanding that they will curate and update their knowledge and methods, train their members, set and enforce standards for the quality of their work, and that they will admit appropriately qualified individuals into their ranks, and that they will always act honestly, in good faith, putting the interests of clients ahead of their own, we (society) place our trust in the professions in granting them exclusivity over a wide range of socially significant services and activities, by paying them a fair wage, by conferring upon them independence, autonomy, right of self-determination and according them respect and status." [1]

Medicine is a craft, and we are its craftsmen. Over time how we describe ourselves has changed, we prefer professionals and its implications rather than craftsmen and images of carpenters, plumbers or electricians. Being a professional has conferred upon us, social and economic status, secure work and a multitude of career pathways. We are a club, with relatively homogenous socio-economic backgrounds and education. This social organization is not new; it is an updated Guild of the medieval period. How has this structure, and the economic and social monopoly, that specialized knowledge facilitates come to be? To begin exploring this question, we must first have a working definition of craft and craftsmanship and then turn to Greek and Roman times and a ‘hinge of history.’

What is craft?

Craft has been with us for ages, although not always with that name. Craftsman take pride most in skills that mature. This is why simple imitation is not sustaining satisfaction; the skill has to evolve. Craft is not simply cognition, it requires doing and as we shall see, there are entwined with one another, they are not separate abilities. Craftsmen apply skills, to make things; cups, bricks, dams, cars. It is an expression of our embodied intelligence, our need to do things that we believe matter. These skills, develop through trained practice, change the craftsmen’s orientation over time; moving from getting things to work, to assimilating technique in a way that at its best allows craftsmen to engage the intimate connection of thought and action in their work – to achieve a mastery.

“Craftsmanship names an enduring, basic human impulse, the desire to do a job well.” [2]

Craft's inner dialogue shuttles between action, intended and actual outcome; allowing an opportunity for reshaping and refining technique, to improve over time. The Susskinds’ refer to this back and forth as problem-solving and problem-finding.

This definition of trained skill and continued refinement is at odds with a modern meme, that of the inspired savant innately enabled, a Steve Jobs. The savant is an attractive belief because it obviates the need for the practice of actions over and over again. But thinking that doing is innate, lives little room to believe that craft results from reflective practice. Are thinking and doing separate or entangled? To understand the basis of this question, the initial schism of hand and head, and to grasp its consequences let us begin in more ancient times, with a number of Greek philosophers.

Archaic Times

Anaxagoras, a Pre-Socratic Greek philosopher, expressed the belief that the hand was the source of our “intelligence.” Craftsmen were honored as demioergos, the Greek compounding of “public (dermios) and productive (ergon).” While their role did not change, their status began to shift for a variety of reasons. Materialism is a belief that all of nature is based upon materials and their interaction; and for the Greeks, nature was the limitless combinations of four elements (fire, water, air and earth) that subsequently returned to their primal origins. Entropy reigned in their world. A desire by the Greeks for permanence rather than change and decay favored less fleeting thought over craft.

“For my wisdom is better than the strength of humans or horses. It Is wholly unfair to rank strength about my wisdom.”[1]

Thought rather than action was felt to be a greater value or virtue. The contribution of the craftsman to the community became separated from their labor, its value lowered. Craftsmen produced, and were known as cheirotechnon, handwork. The intellectual effort of thinking took their place.

The Socratic method is a type of argument that features two opposing points of view; with discussion, one of the arguments is found to be ‘correct.’ Plato answered Anaxagoras Socratically, but appreciating a modern term, complementarity, will benefit our understanding of the schisms brought forth. Complementarity refers to the ability, in fact, the necessity, of having two different ideas described the same object. The idea that light is both a particle and a wave is an example. Complementarity, unlike Socratic method’s winner, take all approach, provides greater insight than either idea alone. ‘Wisdom’ frequently requires the ability to hold complimentary values simultaneously and I have framed Plato’s arguments as complementarities rather than opposites.

Plato believed the hand was the instrument of intelligence, not its source. Plato’s described the human soul as a charioteer controlling two horses, the steady, noble horse of rationality and intellect and the ignoble horse of passion and action. The charioteer through thought guides and controls the horses towards enlightenment. This complementarity, of head and hand, has animated and haunted craftsmen since that time. Craft

“focuses on the intimate connection between hand and head. Every good craftsman conducts a dialogue between concrete practices and thinking; this dialogue evolves into sustaining habits” [3]

For craftsmen, the hand and head are inseparable, unlike Plato’s contention that the head is, well, the head of things. In craft, hand and head are entwined, and while one or the other may be ascendant at any given time, neither dominates. We easily underestimate the role of our bodies because the body is difficult to perceive, its inner workings “shimmer too fast for the eye to see.” [1] It is far easier to experience the role of the mind, as it constantly chatters at us.

"I used to think that the brain was the most wonderful organ in my body. Then I realized who it was who was telling me this." [3]

The second of Plato’s complimentary is the parable of the cave in which object have both an idealized form and a shadow version that we take as our ‘reality.’ This duality remains with craft in the form of standards, functionality and quality. Correctness, representing the ideal, is a standard to which we may aspire but may not reach. For some, Never Events are aspirational rather than functional goals. Quality arises from the dialogue between aspirational and practical; and while an elusive term, most of us believing we recognize quality when we see it. For the craftsmen, the one engaged in making, the recognition lies somewhere between the Platonic ideal and its shadow, the possible – the perfect standard and the functional. Through the entwined hand and head, the work of the hand - information and practice – are embedded into the head, as hand intelligence. This hand knowledge serves as the basis for self-aware critique and further refines hand knowledge.

“Craft quality emerges from this higher stage in judgments made on tacit habits and suppositions.” [3]

Good quality work derives from the relationships of craftsmen to their work based on experience. Without critique, we provide at best, just good enough – the possible. This pole of functionality may foster, over time, mediocrity and the frustration of the desire to do better.

This craftsmen’s dialogue between standards and functionality, the result of focused repetitive practice, is the main forces leading to a craftsmen’s mastery; and as the Susskinds’ conclude “one reason we may have trouble thinking about the value of craftsmanship is that the very word, in fact, embodies conflicting values.”

There was another victim of the schism between mind and body, the central role of our body, our means to perceive the world, in framing our thinking. The division of mind/body, the argument of Anaxagoras and Plato, is central to understanding craftsmanship. Let me take a moment, while craftsmen’s status continues to decline into medieval times, to introduce Guy Claxton’s work, on the embodiment of the mind, which provides another useful set of complementarities to this meditation.

The Embodied Mind - “the human body is not a noun it's a verb” [2]

While our bodies’ workings are, mostly unconscious to us, we are sophisticated “biological constructions.” Our bodies are woven together, ancient collaborations, with foreign cells – the mitochondria – assimilated for their energy production. We also are containers of foreign cells, the microbiome of the gut, with whom we have a symbiotic relationship; where they provide us with nutrients, and we provide a haven with their necessary precursors. Our bodies are organs adjusting the many variables necessary for our cellular survival. Our bodies are motion; we move in service to our survival. We move to find food, to find a mate, to find shelter. Our bodies are a “biochemical soup” [2] of floating cells, hormones, and chemical carrying “news, advice and instructions” [2] throughout the bodies’ far-flung enterprise. The immune system is crucial and its role as our defender, the first quality to be appreciated; but its principal role is maintaining “the body's sense of coherence and identity.” [2] It is a cognitive system arising from unconscious biologic processes and is the poster child for understanding the concept of how ‘intelligence’ emerges from the body – that Anaxagoros’s hand is the source of our embodied intelligence. Each of these descriptive complementarities combines forming a complex adaptive system (CAS) – a system of systems, providing greater stability and integrity than its components. Using the scientific method to understand CAS, we have advanced our understanding of the sub-systems of cells, organs, motion and messaging but the artificial constructs of deduction that leads us this far created boundaries to a more holistic understanding. Everything that we do and everything that we think results from these beautiful mechanisms. The mind does not ride on top; we are not a centralized command and control organization. The mind arises from all the interactions between cells, organs, movement and messaging. Hand and mind are deeply entwined. The mind is defined by our bodies and its abilities. And while this applies to all of our activities, it is with craftsmen that the relationship between body and mind, ‘hand and heart,’ is so obvious.

Medieval Times – the rise of workshops and guilds

In response to their continued social displacement craftsmen developed social organizations to maintain and re-establish themselves. That social history, over three to four hundred years, saw the succession of authority, autonomy, originality and finally embedded knowledge.

Craftsmen initially made a home for themselves in workshops. In addition to being a place of production, it served as a site for passing their skills forward to the next generation. As a result, there was a hierarchy of abilities within these spaces and a need for someone to “be in charge,” to be the authority. The master was by definition, the individual with superior skills, the source of standards and training. Their power resulted from their skill, not rights or privileges. With authority came it's complementarity, obedience.

“A more satisfying definition of the workshop is a productive space in which people deal face to face with issues of authority. … In a workshop, the skills of the master can earn him or her the right to command, and learning from and absorbing those skills can dignify the apprentice or journeyman’s obedience.” [3]

This model of the workshop echoes today in operating rooms were irrespective of the ascendant role of teams, authority remains based upon skill and knowledge. In these modern day workshops, as well as those of medieval times, inequalities of ability are experienced personally and directly. The right to command, the necessity and the dignifying role of obedience persist.

Then, and now, single workshops, individual practices organized in some form of cottage industry could not survive. Collective organizations, like guilds, could wield the economic power to protect their members and enhance their status. The transmission of skill from generation to generation, disciplined internally by standards of craftsmanship, was the guild’s ‘knowledge capital’ and their source of economic power.

In learning a skill, one goes from novice to expert. Beginners are taught and follow “the rules,” the basics of any craft. With time, novices having assimilated many rules recognize their nuance application in varying situations; abandoning rote thought, asking instead “What kind of situation is this?” Integrating these meta-rules situational analyses gives way to identifying priorities, applying more sophisticated skills and knowledge. As prioritizing becomes more ingrained and intuitive, you appear to “scarcely need to think or analyze the situation at all” [2], you are in the flow, you are a master. One easily assigns apprentice, journeyman, master to these modes of thought. Those roles, with little real change, continue today; with modern names, resident, fellow, attending.

The apprentice was bound to a particular master, typically for a seven-year period, who was responsible for training the apprentice, in the core skills of craft. These skills were taught in a face-to-face manner, primarily by imitation. The apprentice was rooted to a particular master and location. When the apprentice presented and had accepted their chef d’oeuvre, their masterwork, demonstrating elemental skills – the vocabulary of the craft, they advanced to journeymen. The successful completion of a ‘chief year’ manifests the skills of the resident, echoing the transition from apprentice to journeyman.

The successful medieval apprentice now journeymen spent the next five to ten years demonstrating the ability to refashion the core vocabulary of craft in new ways and managerial and leadership skills. Learning was more autonomous and exploratory, less imitative. Journeymen were no longer place-bound, but could and were encouraged to travel from city to city absorbing nuances of craft from different masters and workshops. At the end of this time, they presented a masterwork to the masters of a town other than their apprenticed home; demonstrating not only competence but moral behavior and ability to work with the ‘strangers’ who were his judges. Then, and only then, would the journeymen be elevated to a master and be allowed to fully autonomously practice their craft. The obedience of the apprentice had given way, through the learning of the journeyman to the autonomy and authority of the master. With a little reflection, we see the modern day equivalence in fellowships, Board examinations and obtaining ‘privileges’ in hospitals.

The guild’s social structure was anchored to a particular town, supporting both place-bound masters as well as traveling journeymen. They were a union, held together, in part, by the rituals of training and social support. Guilds imposed tolls and tariffs to restrict outside goods from entering the city and developed uniform contracts for work by its itinerant journeymen workforce. It provided contacts and a social structure that supported the itinerant journeymen in their training. The craft guilds, while being a collection of individuals, presented a more collective anonymous face to society. Guild members were often addressed by their craft, rather than by their name.

As medieval times gave way to the Renaissance, some of the masters aspired to more than anonymous work of high quality, the conversation of authority and autonomy had a new member, originality – and the birth of the ‘artist.’

Renaissance – the rise of the artisan

The new artisan-masters valued originality, the ability that the journeymen had demonstrated in their explorations and reimagining of their work. While the craftsmen’s workshop appeared the same, bustling with assistants in various stages of training, its purpose was the creation of the master’s unique expression, the Renaissance version of branding, rather than on high quality ‘mass’ production. Attachment to a particular maker displaced the guild’s preoccupation with a specific locale of the craftwork. Entrepreneurial craftsmen did not need to support training for autonomy; they needed to emphasize exact imitation. This shift had consequences.

Originality is a trait of individuals, not collectives and success requires personal relationships between craftsman-artists and consumers. Innovation required a new purchaser, a new market; it required patrons. The power within these relationships was asymmetric. The patron could and did dismiss the craftsmen-artists at their pleasure. Craftsman-artists found that

“originality does not provide a solid social foundation of autonomy.” [3]

The freedom granted by the collective were lost, the guild monopoly gave way to ‘market forces.’ Today's market economy of third-party payers, the real patrons of physicians, faces similar issues of asymmetric power and autonomy.

“Originality gave a particular importance to face-to-face relations in the studio… the artist’s assistants had to remain in the physical presence of their masters; originality is hard to write down in a rulebook.” [3]

A greater consequence occurred within workshop organization. Innovation increases the difficulty in transferring hand or tacit knowledge. The knowledge of originality is held individually and is hard to leverage to many people at once; furthermore, it is the economic interest of the master to restrict this most valuable resource. In the guilds, the role of the master not only train but to explain themselves to their trainees, to foster autonomy. Authority and autonomy are balanced. In the workshop of the craftsmen now an artist, this balance shifts, autonomy is of no value, and silence – failing to share the tacit and explicit – is the key to economic success. These consequences underlie why the works of Cellini or Stradivarius cannot be replicated to this day. Originality did not remove the need for standards, but it did, perhaps, diminished the desire by the assistant to strive for consistency. Consistently achieving high standards was the job of the master. It began to make sense to find other means of reaching this goal. Machines and industrialization would become the found solution.

Industrialization – the rise of the machine and embodied knowledge

The eighteenth and nineteenth centuries saw the rise of mechanically produced crafts, because investment in machines, then and now, is less expensive than investment in labor. Machines represented the embodiment of explicit knowledge, of how to make or do something, and the craftsmen’s workshop gave way to a new, and much different home, factories. The transition from studio to the factory was difficult; craftsmen fought this change in several ways. With their employers they sought specific contractual arrangements for their ‘protection’; with their replacement workers – the less skilled – they incorporated them, brought them within the craft fold. Today’s physician craftsmen are no different; how are bundled care payments different than union contracts? Aren’t scope of practice and supervisory regulations for mid-level providers (nurse practitioners and physician assistants) a means of bringing them into our fold?

But with machines craftsmen did not fare as well. Rather than controlling their destiny by controlling the devices, craftsmen opposed them hoping that human individuality would triumph over ‘inhuman’ production. That was not to be the case. Today this battle lingers as we enjoy the abundance of machine labor while lamenting the loss and lifting up artisanal products.

The shift from handcrafted to machine was reflected in social thought as well. Around 1807, the 3 R’s of education, initially reading, reckoning (math) and wroughting (making), found making replaced by ‘riting. Today we have words describing proficiency in reading, literacy, and reckoning, numeracy, but there is no equivalent “ability to understand, appreciate and value those ideas which are expressed through the medium of making and doing.” [2]

Before considering the untoward consequences of machines for craftsmen, we should first acknowledge their huge advantage. Speech allowed sharing information and coordinating activity. Writing enabled us to “‘freeze-frame’ our intelligence-in-action[creating] time to reflect on our work-in-progress,” [2] to make memory less transient. Machines allow us to embody aspects of our skills in sustainable smart objects. Machines exponentially increase our societal memory and expertise. They are scalable in a way that bespoke, individual or original, craft is not and as a result, they provide considerable economic efficiencies.

Sennett describes two forms of machines. Replicants mimic our work or activity – a pacemaker is a replicant functioning in the same way that the AV node works. Robots, on the other hand, enlarge or amplify our abilities but are not bound to act as we do. The robotic worker on the assembly line does not weld in the same way as a human factory worker but is far more consistent and efficient. “The replicant shows us as we are, the robot as we might be,” [3] replicants are less discordant, less threatening. There is little social upheaval associated with pacemakers, other than perhaps, who is responsible for their costs and care. Robots, because they are so much more consistent and efficient and because they act in ways that are difficult for us to understand, are more disturbing and threatening.

While machines were ‘designed’ to carry out repetitive activity of the less or unskilled, their effect has been the opposite, replacing more expensive skilled labor with the less skilled. The error of the craftsmen of the first and second industrial revolutions was that they chose to fight rather than to engage and co-opt machines. Machines were imposed upon craftsmen, rather than evolving, as tools had for millennia, from within the craft. Design eliminated the necessity for craftsmen to control them. While physicians as professionals believe they are immune to these forces, doctors as craftsmen are not. Consider electronic health records, a tool designed and imposed upon us by information technology companies rather than evolving from within. The path forward, then and now, is for craftsmen to direct or employ tools that they fashion, even if they are capable of creating a superior product. Incorporating machines into the dialogue of craft are the means of collaborating rather than competing with devices; we will never win the competition.

Career comes from the Latin and French for road, a linear pathway. For most of history craftsmen have had a well establish career path, from apprentice to journeymen to master, from medical student to resident/fellow to attending. Today’s skill society requires a collection of competencies rather than a single ability. In this setting, of jumping from project to project, craftsmanship is in jeopardy because it ‘is based on slow learning and habit’ rather than a portfolio of projects. But before considering some characteristics of craftsmen, let me again take a moment to return to Claxton’s embodied mind. There are insights into the physiology underlying our craftsmen’s actions and aspirations to uncover.

Consciousness, Desires, Emotions

Knowledge can be unconscious, tacit knowledge, or conscious and therefore shareable, explicit knowledge. But why are some forms of knowing available to share and others are hidden, even from ourselves? To understand the concept of consciousness Claxton offers two metaphors, unfurling and welling up. Claxton argues that any of our actions consists of a “process of rapid evolution from a subcortical glimmer of meaning into an elaborate complex of sensory and motor activations across the brain as a whole” [2] – like a fern, whose fronds unfurl as it develops. Physiologically neurons are firing in a particular pattern, yes it is complex, but at its basics, it is very simple. There is no requirement for control of the process. It unfurls once initiated. Consciousness, on the other hand, wells up, in the way we experience tears welling up when we are sad. Claxton's welling up is a “deeply embodied metaphor,” [2] and he uses sneezing as an example to explain the distinction in his two metaphors. Sneezing is noticed, welling up, as it gathers strength and pattern; its initial unfurling is not. In his view, all conscious thoughts well up from unconscious furlings; consciousness is not the basis but the result of our brain’s activity.

Welling up is awareness, focus or attention and to some degree, we set thresholds for welling up to occur. Welling up may be quite rapid, and we do not notice the unfurling. In other instances, welling up is blocked, when “the word is on the tip of your tongue.” Or it can be slowed as our frontal lobes interject editing and inhibition when we “catch ourselves in the act.” Welling up can make our actions awkward, when we are “self-conscious.” or rushed, when we “jump to conclusions.”

In the world of craft, doing resides in the unfurlings, creating a personal, but not necessarily conscious understanding; after all, the ability to articulate what and why you are doing is unnecessary for you to do your work. The necessity to explain oneself results from needing to communicate the how and why of your doing. Tacit and explicit knowledge both unfurl – only explicit knowledge wells up.

“Needs, deeds and see’ds” [2]

Our actions reflect three considerations, in Claxton’s words, “needs, deeds and see’ds.” [2] Needs reflect the range of concerns and priorities, current desires. As we mature, our needs increase and diverge creating, “a substantial, fluctuating, partly conflicting portfolio.” [2] Deeds represent know-how, “portfolio of capabilities”[2] ranging from the deeply embedded, i.e. unconscious control of heart rate, breathing and blood pressure to the conscious ability to articulate thoughts in words or to hit a baseball. See’ds, or opportunities, result from comparing needs and deeds – allowing us to “select and craft my actions appropriately.” [2] In the view of embodied intelligence the mind is not the source of needs, deeds or see’ds, but “hosts conversations” [2] between these streams of conflicting information.

Sometimes, our conscious mind cannot make a decision and we opt to “go with our gut.” This metaphor, to act on your intuition or emotions draws from the embodied perspective. Feelings, in an embodied sense, give actions context and are frequently archetypical responses to events of importance. For Claxton, emotions are

“states of readiness to respond to events that, we suspect, might be about to unfold.” [2]

Feelings are our body’s way of characterizing both “value and concerns;” acting like pre-sets in an audio system, allowing us to switch our attention and physiology quickly to conditions we perceive. Emotions “sets up patterns of expectations and prediction: some constellations of attention, memory, thought and image.” [2] A concrete example is worthwhile. Fear arises in the anticipation or appearance of danger. Our physiology shifts with the release of epinephrine, our heart rate, and blood pressure increase, we are more attentive. Large muscle groups tense, our outward appearance changes – eyes more intently focused, signaling our feelings to others. We are primed for fight or flight; fear's pre-set requires no conscious control or awareness.

Emotions are a collection of these pre-set primings developed through evolution because they are useful for survival. Pre-sets, “constellations of bodily states and activities”[2] can be blended creating a palette of feelings, which subsequently influenced by societal, familial and individual factors.

Characteristics of craftsmen

The needs, deeds, and see’ds along with value characterizing feelings or emotions result in traits we find within and among craftsmen. These qualities include a consciousness about the materials they fashion, cognizance of the interplay of hands and brains in doing and exploration and ways to communicate and transfer skills. Craftsmen are aware of the roles of tools, quality, resistance and ability in influencing craftwork.

Material Consciousness

Concern about the materials we craft, for physicians it is our patients, is the basis of all good craftsmanship. If emotional states of curiosity and inquiry, priming us to look and act in certain directions, are the heart of material consciousness. Curious questioning begins with a need – an ongoing problem or predicament to resolve, the problem solving and finding underlying craft and professionalism. Simultaneously there is an opportunity to explore the current situation and recognition that inquiry is not a significant bodily threat. Satisfying these conditions allows exploring. A dog approaches an infrequently encountered object. Can I eat it? Watch their halting, episodic approach – I want to know but can it hurt me? Curiosity enables craftsman, at any level of training, to continue learning and growing. This problem initiated interest results in a “satisfying sense of comprehending that which was previously obscure.” [2] All craftsmen seek to be in the flow, effortless labor, unending time, being at one with one’s work. By being curious about materials, we discover newer, better ways of thinking. Journals are great examples of that curiosity. Craftsmen express curiosity through metamorphosis, presence, and anthropomorphosis. Let us consider each in turn.

Metamorphosis – changing a form or nature, is a frequent demonstration of material consciousness involving incremental changes. When an expected behavior doesn’t occur or in the face of failure, we analyze our practices.

“the analyst’s first port of call is its details, its small parts. These clamor immediately for attention and … may then change and evolve.” [3]

Salutary failure or beneficial failure is valued because it revises our behavior and is a craftsmen’s frequent dialogues. Salutary failure is a hallmark of medical care, although we call it morbidity and mortality conference. Entrepreneurs evidence helpful failure in the assertion to “Fail fast and fail often” to achieve a viable product. This metamorphosis is grounded in doing and judgment – the daily practice of craft; it does not emerge from theory or abstractions.

A more difficult metamorphic form is admixture, combining somewhat disparate elements. Laparoscopy as compared to open surgery is a good example. When the technique was popularized, and practice changed, open surgery was ascendant and laparoscopy a minor technique of gynecologists, not surgeons. It took curiosity about technology and an opportunity to apply it in a novel way for the change to take place. As we know from chemistry, mixtures can marry components with independent existence, as was the case with surgical laparoscopy; or may be compounded, integrated, where the sum is greater than the parts, as we see in mixing in robotics and laparoscopy today.

The most difficult metamorphosis to create are domain shifts – the change in paradigm discussed by Thomas Kuhn in The Structure of Scientific Revolutions. Here, a tool is applied for an entirely new purpose. Aortic stent grafts are an excellent example, applications of stents in an entirely different domain.

Craftsmen demonstrate material consciousness in establishing their presence in the work – by owning it. Generations of craftsmen have left their marks, literally and figuratively on their work, physicians are no exception. Presence communicates our unique involvement. Many, if not all of us, know patients that ‘only we could treat,’ This is our maker’s mark. Consider the difference in how we speak of and perhaps care for, our patients vs. the patients we are ‘covering.’ Expressing our presence contests the ascendancy of ideas over skill. We are not interchangeable FTE.

“Craftsmanship belongs to those who are trained… in the work; theory is shared with all educated persons. All things are in common so far as theory is concerned… whereas work finely executed by hand or technical methods belongs to those who have been specially trained in a single trade.” [7]

Finally, craftsmen use anthropomorphism investing “inanimate things with human qualities.” There is no better example of this then the metaphorical descriptions we employ for our immune system.

“In the late nineteenth century, white blood globules were not only compared to 'border police' assigned to rebuffing intruders -- an army formed to combat the invaders -- but were also described as a physiological mechanism for eliminating aged, dead cells, at times exterminators of foreign bodies.” [5]

These are not accurate descriptors; they are linguistic ways to communicate how we “value” material.

Hand and head

For theoreticians, technique and technologists are relatively uniform, interchangeable. But for the craftsmen, technique is expressive, nuanced and personal. Technique begins with our hands, an embodied intelligence that acts upon the environment in beautiful and frequently unconscious ways. The hand’s grips let us interact with our world, grasp influences the way we think and act.

The hand is awe-inspiring, its anatomical construction defining many of its most skillful behavior. It is not a passive tool of the motor strip. Through evolutionary design, the hand has an opposable thumb, with a range of motion and length permitting us to pinch and grasp using the adjacent finger. The muscles of the thumb are particularly strong, making those actions reliable. Our fingertips are particularly sensitive to changing texture and resistance. The skin of the hand can accommodate compression and provides friction to improve our grasp of large objects. In our act of grasping a coin, a cup, a ball, this arrangement of bones and muscles anticipates and adjusts without conscious mediation or central intervention; hands demonstrate distributed intelligence.

“the zone of direct interaction with the physical world; the principal arena in which we use our limbs to latch on to things we desire or that interest us or bat away things that are noxious or threatening.” [2]

Objects in our personal space, within our grasp, are perceived differently. A book close at hand is this book; the book on the shelf, that book. Without conscious thought, we know what to do with objects entering personal space – whether to grasp or bat away. Need combines with perception, identifying opportunity. Our metaphors reveal these unconscious thoughts; we “come to grips with an issue” or “have a good grasp of the plan.”

Gripping, unlike breathing, is mostly voluntary. Mary Marzke identified three basic types of grip: the pinching of small objects, the cradling of an object in one hand, and

“the cupping grip … allows us to hold an object securing in one hand while we work on it with the other hand.” [3]

When placing objects, that can be gripped within our personal space; we prepare to grasp them. “The body anticipates and acts in advance of sense data.” [3] Prehension or anticipation is hardwired into our perception. The saccades of vision, the tiny flickering when we read, move retinal images that are filtered out by anticipation. The ability to anticipate permits us to take shortcuts; predicting the outcome we move in that direction. Prehensive cognition is the basis for humor, when what we anticipate is instead replaced by a delightful surprise.

The hand’s abilities inform our thinking in other ways. In hammering a small tack, our grip, thumb alongside the hammer’s shaft, is delicate, more for accuracy than power. In driving a nail into a stud, the thumb wraps around the shaft, power ascendant over precision. In the act of gripping, we simultaneously exert force and anticipate release. Craftsmen release their grip “in the microsecond after force is applied” [3] making their work easier and more accurate. While release is a learned process, it is wholly unconscious. Again, metaphors point to these relationships; we “let go of the problem” or “lose our grip” on the situation.

The hand’s digits have unequal strength and flexibility; that would impede coordinated movement if not for unconscious compensations we apply. The hand works collaboratively, in cooperation – metaphorically, “lending a helping hand”, the hand necessary when we cup an object. This inherent cooperation impacts how we train our hands. Deconstructing the action of our hand does not improve skill. The technical competence of the hand is not analogous to a factory assembly line where optimizing each step optimizes the whole. For a collaborative system such as the hand, coordination of activity from the beginning, perfect practice, is a surer way to achieve competence.

We explore the environment with our senses, touch the prototype is simultaneously the most basic and sophisticated. Through touch, we reveal the world and refine our actions. Consider the phrase, ‘let’s keep in touch” or “he’s not in touch with his feelings.” Touch explores and anticipates, creating expectations that help link sensation and movement. Touch is different from other sensations; it is rapidly communicated throughout the body, and lingers; consider touching a hot stove. Vision, our most developed sense is more quickly attenuated, you shut your eyes, the image is gone, removing your hand from the heat source does not eliminate the pain. The ability of the fingertips to explore enables us to modify our behavior. By being attentive and simultaneously using our hands to explore we identify sameness, difference, better, worse. We become more reflective, and practice is not mere repetition but is an inner narrative.

Exploratory touch is the physiologic model for the

“constant interplay between tacit knowledge and self-conscious awareness, the tacit knowledge serving as an anchor, the explicit awareness serving as critique and corrective.” [3]

“In performance, the confidence to recover from error is not a personality trait; it is a learned skill. Technique develops, then, by a dialectic between the correct way to do something and the willingness to experiment through error. The two sides cannot be separated.” [3]

Error correction is another touchstone of craftsmanship. Craftsmanship models our social behavior, how we respond to failure’s lessons. Craftsmanship in on display in our response to morbidity and mortality conference. Because failure is a constant in medicine, it may be useful to consider Claxton’s definitions of emotions common to failure. Sorrow is an irrecoverable “loss of a stable, valued part of your world.” [2] Craftsmanship is personal and inadequacies of individual performance are painful, eating away at self-confidence. What if your best was not good enough? Sorrow faces inward, creating space to reflect and put failure into perspective. Sorrow is the basis for salutary failure. But there are more destructive emotional responses to failure, anger, blame and guilt.

Anger – when one’s “assets or resources are under threat from another being who might be susceptible to intimidation.” [2] At risk is our self-worth and self-confidence and rather than turning to inward reflection, we project and intimidate, making the accuser back down. The phrase, “don’t kill the messenger” captures our angry response. Shame and guilt result from transgressions of “social norms and standards … risking [our] being demoted or cast out.” [2] When transgression is unintentional, we experience shame with its physiologic and mental repercussions. Physiologically, there is muscular tension, impeding release and degrading technical competence. Mentally, shame and attendant anxiety degrade our ability to reflect and subsequently correct. Shame is counterproductive to meaningful learning through error and resulting in “loss of initiative and a reliance on other’s to indicate the next, or the correct course of action.” [2] Guilt is a more intentional transgression, multiplying shame’s impact many folds.

Communicating Skills – Instruction

Skill requires a reliable, flexible repertoire of deeds, a broad perception of see’ds – “opportunities for action”[2] and ability to anticipate the outcome of their combination. These components are intertwined and must be learned synchronously in the presence of all three qualities, rather than serially. How are skills transferred? We learn skills through noticing – focusing our attention, by imitation – creating templates from masters and the more skilled, and from doing.

"Show don’t tell" is the simplest means of communicating skill from one to another. It is the medieval method and it is hard to improve. Show requires presence, physically and mentally. Show don’t tell can incorrectly assume the apprentice absorbs the master’s demonstration and direct imitation results. This assumption places an unequal burden upon the learner, not teacher. Show occurs in our workshop, the operating room, the surgical floor and perhaps to a lesser extent through video. Language is a frequent adjunct in expressing more fully what we are doing. The show don’t tell of the operating room, allows for spoken word, visualization, participation, and questioning. Video that shows and tells at once is often more instructive than written instructions because language alone is often a poor means of depicting action;

Consider this typical passage in performing thymectomy:

“The right phrenic nerve is identified. The right inferior pole is identified and dissected from the pericardial fat pad, dividing attachments to non-thymic tissue.” [6]

So many verbs – identified, dissected, dividing – so many seeming actions, but these verbs name rather than explain actions. The tacit knowledge of identifying, dissecting and dividing is absent, what is self-evident to the master is not explicated for the learner. How can we more easily share tacit knowledge, knowledge that we experience unconsciously? First, one can instruct by adopting the beginner’s mind – the time when knowledge was unknown – and combine it with the masters’ ability to anticipate difficulties. Now, as instruction proceeds the means of identifying the phrenic nerve are described as the actions are carried out. Moments of difficulty become teaching moments. Confidence is facilitated as the instructor shows how a new work builds upon older, already incorporated lessons – incremental learning builds upon basics to achieve complexity.

Second, when skills are applied in a new setting, when the domain shifts, narratives set a scene, incorporating ‘anecdotes and observations’ not directly related to the procedure. The narrative of the master describes the similarities and differences between the known and new. Prior, ‘lateral knowledge’ serves as an anchoring reference point from what the learner already knows to what they are about to learn.

Frequently, metaphor can be used to create the framework for learning. Our physical experiences, become metaphors to understand abstract ideas. Consider some bodily actions: we grasp, leave, get into. Metaphorically, we 'grasp' ideas, we 'leave' the argument for another day, we 'get into' ourselves. The commonality of human's sensory and motor systems provide metaphor’s advantage, expressing abstractions in an accessible, tangible way. While most metaphors are concrete, they can be more ambiguous, allowing alternate meanings. Metaphoric instruction seeks to impart the essence of the action, its role, its gravitas within the whole activity. It helps to express craft’s nuance, both of thought and technique.

The goal of learning by doing is to create facile, automatic skilled movement and that requires practice. The contemporary meme is that it requires 10,000 hours which even with the restrictions in work hours can amount to at least five years of training. But lost in the meme is the quality of that repetitive doing. Smart practice is

“monitoring your own progress, setting realistic goals, designing your own training regime, knowing when to take breaks and when to push through, picking out the ‘hard parts’ for special attention, knowing who to ask for what kind of help, and where to place your attention.” [2]

It is the practice of deeds and see’ds concomitantly, using focus to identify obstacles and resistance that is the work of being a craftsman.

Tools

Consider the forgetful patient, the one labeling their cabinets, keeping a to-do list, writing everything down. These labels and lists are ‘tools’ serving as extensions of them, in this instance, extensions of memory. These tools allow our patient to live comfortably, “to offset the increasing limitations and fallibilities of their own biological systems.” [2] We routinely use tools to amplify our abilities and body's intelligence. Tools are physical representations of society’s accumulated knowledge.

Tools enhance or create entirely new capabilities. Identifying tools that improve our abilities is relatively easy, a retractor or a vascular clamp, containing or occluding, extending our hand’s skill. But even in extending our skills, they remain separate from us. Richard Dawkin’s describes a different set of tools, ones “extending [our] phenotype,” tools that merge with the craftsman. Consider the DaVinci surgical robot. The surgeon sits at the console and engages in their work. The action and thought of the machine and surgeon are inseparable. The DaVinci blends within our personal space. Perhaps it is better thought of as a prosthetic limb, than as a tool. The craftsman’s merging, bonding with tools underlies our attachment to ‘our favorite’ tools. In the same way, that taking the labels and lists from our forgetful patient changes them, changing or removing our tools is changing or removing us. That is perhaps why, we cling tenaciously to some piece of OR equipment, graft, or stent when we offered an ‘equivalent’ alternative.

Tools can be fit-for-purpose, like a retractor, or can be simpler, tools with an ill-defined function that paradoxically facilitates a range of uses. The scapel of Vesalius was such a tool. It was sharp, and as we all learned in gross anatomy, a slip resulted in less than perfect results. But in skilled hands it did more than cut, it could be used to scrape and separate Ill-defined tools, allow craftsman more latitude in their actions, opening up serendipitous discovery. Hume described growth as a ‘stumbling’ on the unexpected. Ill-defined, all-purpose tools facilitate stumbling’s transformation into intuitive leaps and growth, in the prepared mind of the craftsman through rethinking or redefining ambiguous uses.

For example, consider the partial gastrectomy an operation designed to treat ulceration. In rethinking, we recognize that partial gastrectomy always resulted in weight loss. Then in the difficult part of the intuitive leap, there is a domain shift. What if we were to blend the operative management of ulcers with the field of weight loss? The more one considers the possibility, the more clearly the ‘side effect’ of partial gastrectomy is the ‘main effect’ of weight loss surgery. In the prepared mind, the tacit knowledge of operations resulting in incidental but consistent weight loss becomes conscious. There is a recognition that some procedures might be applied when weight loss is a goal. From this recognition, the field of bariatric surgery was born. Later, the intuitive leap is discovered not to be a panacea, problems remain. In the process of ‘solving’ a problem you have identified other problems. The range of procedures, invasive and not, available for bariatric care demonstrates this principle. We return to the problem solving, problem finding work of the professional.

Resistance

No matter how skilled the craftsmen, there is resistance of materials to ‘bend to our will.’ In some instances, these moments result in salutary failure. But are their skills that a craftsman applies to overcome these sticking point? Are there skills we apply to situations when patients, irrespective of their intentions, do not readily accede to our plans?

Craftsman recast problems, rethinking their skills to find an alternative means of achieving the same goal. This rethinking is the backup to our anticipated surgical care or medicine’s alternative care plans. Unable to do aortic reconstruction, consider extra-anatomic bypass. Unable to safely reestablish colonic continuity, place a protective stoma.

A good craftsman applies patience, the capacity to linger and concentrate in the face of frustration. Ever surgeon, when confronted with a difficult operative moment, pauses, regroups and then proceeds. We revise our time expectations to achieve the outcome we desire or in more dire circumstances, we change our expected results. Sennett refers to this as “the temporary suspension of the desire for closure.” [3]

Finally, craftsmen identify the ‘most forgiving element’ of the frustrating condition. Because it requires both patience and rethinking, a re-envisioning of what skills to apply and how to proceed it is a craftsmen’s greatest struggle. If the artery is too calcified, perhaps a patch rather than replacement. Tissue friable? Resect a longer segment.

Where in our working life do these episodes of resistance occur? The answer lies in analogy with living cells that have two ‘sites of resistance.’ First, the cell wall, an exclusionary boundary; second the cell membrane, a more porous border. The cell wall is a safe zone – work can and will be productive. It is the controlled environment, the typical case done typically, home of the routine. Repetition deepens one proficiency, but will not expand one’s skills. The porous border is a site of exchange and flux; change is the constant here, home of the atypical. Resistance lives at this border, the opportunity to fail or make intuitive leaps, to grow and experience happen here.

Play

The dialogue between craftsmen and their material has its origins in the rules we make as children, playing. Our first rules are often dysfunctionally tilted to our advantage. “Head I win, tails you lose.” But, if we insist on these rules, the other children go off to play with others, leaving us alone. A workable set of rules for keeping score requires collaboration; all the participants must agree, they are inclusive and consistently applied. Consistent, collaborative rules allow for repetition; we can play the same game again and again. This ability to repeat a game “lays the groundwork for the experience of practice.” [3] Practice modifies our expectations; T-ball is different than Little League. We change rules based on the expectations of experience. We learn that “to get better at a skill we need to modify the rules.” Altering and experimenting with rules, results in learning. The experiences of play are manifest in adults taking ambiguous, all-purpose tool, and playing with their possibilities, exploring what they might do.

Ability

Ability, competency, talent – whatever term you chose – while not in short supply follows a gradient. The greater the ability, the fewer number of individuals identified. But exceptional, innate talent is not the basis for craftsmanship.

“Craftwork embodies a great paradox in that a highly refined, complicated activity emerges from simple mental acts like specifying facts and then questioning them.” [3]

We have seen the many inherent capabilities of the human hand. And while each hand is visibly different, the difference between being able and being a klutz resides more in how hands are “stimulated and trained.” The ability of craftsmanship come initially in locating where in our actions “something important is happening.” Paying focal attention to what we are doing helps us to see what seems “not quite right.” From this dissonance comes the craftsman’s questioning, to understand the source of the “not quite right.” Neither of these actions, paying attention or examination are innate or intrinsic; they are learned. And both establishes craft’s rhythm of improvement; we act, question our results, and then we act again, in a new way. This final step being “open to doing things differently, to shifting from one sphere of habit to another” is also learned, not innate. Being open to change is difficult for many of us, we are sclerotic in our habits, they have served us so well, and change is not only uncomfortable, but it requires energy we are sometimes not willing to expend. Openness to change is what makes us masters and separates us from journeymen.

Quality

Quality-driven is the mantra for many organizations. Driven, synonymous with obsessed, relentless; “attending to all cases, letting no exceptions slip by through carelessness or indifference.” [3] Good and not good enough are linked for the craftsman, who recognize the difference. Quality becomes a badge of distinction, a claim of superiority.

In the early history of craft, especially the age of guilds and artisans, sociability was a requirement. The rituals of the guild, the face-to-face structure of the workshop and their existence within small communities all fostered social bonds. Achieving quality in one’s work provides insight applicable to social interactions. Resistance and failure are as instructive in building relationships as in working materials. The rhythm of craft, anticipate, act, reflect, and revise is the rhythm of our relations with others. Sociable expertise is more concerned with outcomes than with self-vindication.

With the rise of factories and bureaucracies, social obligation proffered by professional associations, weakened. Work slowdowns, no show jobs, ‘its not my job,’ are egregious examples. Many of today’s professionals make the artisans’ error, believing their skills are ineffable and unique. This unfortunate consequence of the ‘badge of distinction’ results in craftsman placing themselves above others, acting in less social ways towards their peers and clients.

Physicians, as experts, “with knowledge that allows them to see beyond the elements of a technique to its overall purpose and coherence,” [3] dominate the relationship with patients. Antisocial expertise, social skill’s evil twin, emphasizes their superiority. The antisocial expert produces humiliation and resentment using invidious comparison – comparison presented in a way that arouses resentment. The antisocial expert does not empathize, they instruct, they do not share, they direct.

The Future of the Professions

Patients seek the help of physicians because we know more about medicine. This knowledge is our fundamental offering, the heart of our power. Inevitably, our greater knowledge makes our relationship with patients asymmetric, creating increasingly contentious issues. Issues involving trust arise directly from the asymmetry of authority and knowledge.

“All other dimensions of professional service … are secondary factors. Were it not for recipients’ limited understanding and corresponding need for knowledge, there would be no trust required, no reassurance desired, no quality to control, no training to deliver, no services or behaviors to regulate. This is elemental. …Without this ingredient, other factors, such as trust and training, are of no relevance…” [1]

The professions are a social construction; the way society shares knowledge. In our role “to develop, curate and provide access to that knowledge” [1], we have distributed knowledge through medical schools, libraries, textbooks; social constructions designed to serve our needs directly and those of the patients indirectly, through us. Our curation controls access while developing new knowledge. Professionals, like the guilds before them, seek economic protection and advantage, and this deepens asymmetry rather than lessening it. We know, from our past, the dialogue between authority, autonomy, and artistry. The modern profession of medicine places autonomy and artistry in ascendance, rather than collaboration. Put bluntly; we do not share nicely among ourselves. Rewards are to individuals, even though the bulk of care provided today if from teams. CMS and other government agencies are as guilty of this as are our professional organizations which continue to be collections of individuals branded together rather than collaborative groups of craftsmen.

Knowledge

What is the experience that we find so necessary to hoard for our advantage? There is know what, didactic materials, our current dogma found in textbooks; understanding of undergirding processes, learned in medical school and journals, and the ability to know where to seek additional help and expertise. There is know-how, the tacit, tightly bound unconscious knowledge of experience – when to apply or withhold action. Despite our economic desire to restrict know-how to our guilds, to build a fence between our 'clients and us’, the characteristics of knowledge in the digital age undercuts this effort.

Economists define ‘public goods’ as non-rivalrous and non-excludable. Non-rivalrous just means that the goods, in this case, medical knowledge is not limited. There is enough pie for everyone. My being able to do a bypass does not diminish your ability to do a bypass. Access to medicine’s knowledge seems rivalrous because a limited number of practitioners deliver our understanding in a face-to-face manner, in the tailored manner of craftsmen. Access is an organizational bottleneck, a result of how we have socially constructed providing expertise. Non-excludable, means that everyone is entitled, we all share; we exclude no one. We can thrash all we want, but no physician can ethically deny care to a patient in need. We may pretend that continuing need is different than acute need and try to shunt the chronic problems unto others but in the end, everyone receives care. The Affordable Care Act, Medicare, Medicaid, private insurers – all attempt to disentangle the exclusion permitted by the grand bargain from knowledge’s innate non-excludability.

Knowledge’s non-rivalrous character makes widely used information more valuable.

“the use and reuse of existing knowledge can often lead to the generation or production of new knowledge.” [1]

In an increasingly sharing economy, Facebook is more powerful than its gated, niche predecessors. Sharing increases the power of the commons rather than the individual – another impasse to our grand bargain. Finally, knowledge, unlike physical objects can be digitized, stored and used electronically, it is ethereal in nature. Machines are no longer dumb; these replicants contain embedded knowledge. Twenty years ago, rates of fluid administration were calculated by the nursing staff by watching the drip chamber, the intravenous pulse. Today, pumps can be set automatically, know what they are administering and provides alarms to manage them. Not all knowledge can be digitized, the problem faced by the apprentices in learning from their masters remains, tacit knowledge is difficult to make explicit. But as members of a profession, whose currency is knowledge, we need to recognize that the forces of automation will wash over us as they did our craftsman ancestors.

Trends impacting the economic role of the professions

The Susskinds identified four trends catalyzing the end of professionals as we know ourselves. There is the move away from craft, the continued disintermediation of gatekeepers, a shift towards proactive management and the drive for increased economic efficiency – cost savings. We have described the bespoke, individual creations of craftsmen-artists, the one-on-one project. It is practically impossible to care for patients outside a team environment. While we all believe that our patients do best with ‘our’ care, we are increasingly willing to have others care for them after 5 PM and on weekends. It is unclear whether society will view this as a complementarity of the grand bargain or a contradiction requiring resolution.

Within the profession, the gatekeeping role of the specialties is dissolving. We have interventional neurologists and nephrologists, cardiologists doing endovascular care, family practitioners providing Botox. We are doing “each other’s work.” And this extends to mid-level providers, nurse practitioners, and physician assistants, who are challenging the traditional scope of privileges. The disintermediation involves organizations as well as individuals; hospitals supplanted by outpatient surgicenters, infusion centers, pediatric emergency rooms and orthopedic centers.

Traditionally, patients recognize that they have a problem before they seek our assistance. They initiate the encounter, which is paradoxical because we burden the less knowledgeable with identifying the need.

“People generally prefer problem-avoidance and problem-containment to problem-solving. In short, they prefer a fence at the top of the cliff to an ambulance at the bottom.” [1]

While we have been reactive, professionals are increasingly proactive, witness the industry of screening tests and preventative care. Additionally, those smart machines, embedded with knowledge are invading our lives. The individual glucometer that alerts the patient and physician already exist. Quantified health, the rise of the Fitbit and its peers, enables patient’s more proactive stance.

And of course, there are always in a world of limited resources, concerns about cost. Physicians, as well as other professionals, have recognized this particular problem trying to lower costs by strategies of efficiency; the substitution of mid-levels in place of physicians, the use of disposable and remanufactured equipment, etc. They also employ strategies of ‘collaboration,’ bundled care is a great example, as is the rise of hospitalists or the employment of dedicated specialists within larger specialty practices, for example, podiatrists, neurologists and physiatrists in orthopedic groups; or a cardiac surgeon employed by a team of cardiologists.

The Professions respond

In the face of these winds of change, the Susskind’s describe a model of how professions are changing; like all models, it is a simplification. Professions and professionals find themselves at varying places along a continuum that begins with bespoke, face-to-face services; the care traditionally provided. Even here, things are being done differently. Consider concierge physician who like the medieval artisan, have a set of patrons, deliver services to them and serve at their whim. The same issues of autonomy and succession that distressed the Renaissance artisan loom large for concierge care.

Moving from bespoke service comes standardization of care – harkening back to the craftsmen’s workshop, especially that of the artisan, where all processes were done in a particular manner. Standardized routines prevent duplication of effort, they are more efficient, providing consistent quality. Checklists, standard forms, order sets, alert algorithms, we embrace routinization, enabling us to provide consistent care to many people. One of the reasons for our acquiescence is these routines are internal, a supply side change where professionals are a primary beneficiary. Professionals drive standardization and routinization because of concerns about preventable errors, issues of quality; not over costs. As Atul Gawande has said

“And the reason is increasingly evident; the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely or reliably.” [1]

In contrast, demand side, external routinization, delivers a service once, that many users can benefit. LegalZoom is an example of this type of service. Clients benefit far more from lowered legal fees than the legal profession. Because of issues of control and economics, the professions have been slower to engage these practices.

Another effect of routinization is that these standards, formerly the ‘property’ of experts “can now be conducted by less knowledgeable, even lay, people with the support of appropriate processes and systems.” [1] Aspects of professional work are ‘commoditized’ and like all commodities, there is both an expectation of quality and a financial “race to the bottom” on cost.

Professionals as gatekeeping controllers of access have a long and painful history in healthcare. The experiments of the 80’s making primary care provider gatekeeper to other physician services, proved a disaster, placing unacceptable burdens on the relationship between the primary physician, their patients, and colleagues. The current concept of the medical home faintly echoes this approach. Gatekeeping has another role, acting as the intermediary in the asymmetry of information. Economically, intermediaries who provide no value, who simply takes a fee and sends you on, are wasteful. We see this problem when hospitalists are the primary admitting physician for purely surgical problems. They are not adding value, only cost. Intermediaries can be re-envisioned, “from working as a ‘sage on the stage’ to becoming a ‘guide on the side.”[1] Witness the increasing use ‘medical sherpas’ or nurse navigators.

Standardization disaggregates care into parts allowing work to be re-allocated to lower cost, equally skilled facilities or individuals. The rise of surgicenters is a good example of re-allocation of work to more fit-for-purpose facilities rather than all-purpose hospitals. Work is re-allocated among individuals; when a task does not require superior expertise, e.g. vein harvesting by a physician assistant rather than a surgeon. Or when standardization routines – supervised by ‘senior’ personnel – are provided, e.g. post-operative care by nurse practitioners; and when smart machines can supply embedded technology, allowing medical assistants to obtain vital signs using devices, rather than having RNs provide this care.

Further along the continuum of change is systemization, where knowledge’s digitalization allows information to flow more freely. It is no longer enclosed within a particular geography; no longer locked in that master-apprentice relationship. Moreover, it is no longer subject to face-to-face interaction. It is delivered through electronic means, witness the rise of telemedicine or order sets applied across entire healthcare systems, nationally and regionally rather than locally.

Professionals are far more comfortable with our traditional role in providing bespoke services. Movement away from craft, towards routinization, standardization and systemization make us uncomfortable. We have many objections. That said, we become more comfortable when the underlying means of payment shifts. Attorneys were happier substituting para-professionals when the fee structure went from billable hours to a fixed amount. For physicians, fee-for-service, based upon relative value units (RVUs) are our billable hours. As we bundle care and fee-for-service ends, physicians become more amenable to these forces.

Professional objections

As expected, professionals have many objections to these changes beginning with a near universal belief that, the status quo is best or that medicine because it deals with health, life, and death, is an exception to the need for change, for surrendering the grand bargain. There is a ‘lost-craft’ objection that by being standardized we will lose our traditions, especially our autonomy, our sense of worth and dignity, status and prestige. Standardization splits skill from outcome; outcome is the goal. The lost-craft seeks to keep skill and the need for personal interaction ascendant. Especially for surgeons whose hands create a ‘cure.’ Many surgeons believe that this is the best way to deliver care, providing optimum care for ‘their’ patient. It harkens back to the artisanship of craft, originality. But often, that same surgeon is more than willing to take the weekend off and let their covering physician take charge. Now, any willing provider is adequate. It is a contradiction to believe we are special, although interchangeable on the weekends. Each of these arguments is a perverse “means justifying the ends;” can we honestly say that outcome is less important and wholly independent from how it is achieved?

Others object to these changes because they believe that the human interactions of medicine are valuable in and of themselves, arguing about a central role for empathy. But given this argument can we identify physicians, less able to be empathetic and that appropriately and with great effectiveness provide empathetic substitutes, nurse practitioners, nurse navigators and so on.

As second bias we share with other professionals is termed ‘technological myopia,’ – that is the “tendency to underestimate the potential of tomorrow’s applications by evaluating them in terms of today’s enabling technologies.” [1] Technologic displacement, a fancy way of losing our job, are the concerns of our eighteenth and nineteenth-century craftsmen brothers. Most professionals embrace automation if, by automation, you mean identifying activities that can be readily computerized, like factory or paperwork. Most experts accept automation because it doesn’t impact them – or so they believe. But this type of automation has already come to medicine, in the form of innovative systems providing lower cost or great convenience, e.g. urgent care centers. A less aggressive, but ultimately more impactful innovation is the creation of new and different services – not replacing people or practice – but enhancing it. The classic example would be telemedicine extending a physician’s clinical reach to patients unable to regularly access their services.

Then there is the issue of robots – machines enlarging our abilities. One common mistake is believing machines are not as smart as we are because they cannot think as we do. That confuses replicants with robots. Big Blue beat Garry Kasparov because it could calculate millions of chess moves, it was a statistical bludgeon. Google’s AlphaGo AI bested Lee Se-dol in ways that its creators do not understand. It has its own intelligence. Requiring machines to be anthropomorphic copies is a false limitation. Robots are already here; the DaVinci system augments its human handler’s dexterity and actual reach. Robots are in our homes, those cute Nest thermostats, which monitor or sense the environment and act autonomously on our behalf. These same simple systems can be deployed throughout hospitals. Many patients, before suffering a cardiopulmonary arrest demonstrate trending changes in heart rate, blood pressure, and pulse. These trends are lost in the virtual and actual noise of our intensive care units, but dedicated systems can provide an early warning of impending critical events; an interaction that a machine does more attentively than the critical care staff. And robots are becoming our companions. Not R2D2, at least not yet; but Siri and her friends, smart assistants that can anticipate our needs and increasingly our mood. What is to say that these voices will not be an interface to our patients, fulfilling the screening functions we pay other humans to provide now?

As professionals we need to accept the idea that machines have roles outside the comfortable, to us, ‘back office’ jobs. For some tasks, machines will be our companions and collaborators, DaVincis, extending our reach but not particularly threatening. But for other tasks, we will have to recognize as did Kasparov and Se-dol that machines are ‘manifestly superior’ and that some or all of our functions will be replaced. This is disquieting. What are we to do? We can dredge up the separation of process from the outcome. But can we make a sustainable argument “to reject machines in favor of less capable humans,” [1] and in a world of diminishing economic resources, can we afford the extra cost for people in these situations?

There is one argument to be made in our favor in these circumstances. We have already seen its glimmerings in the discussion of self-driving cars. When there is an accident, who is responsible? The car, the ‘driver’, or the software; the courts have already found that autonomous cars have no drivers.

“However, it is harder to grapple with the notion that the buck actually stops at a robot, that a machine might be regarded as in some sense responsible for important moral decisions such as whether to switch off life-support systems, put down a household pet, concede custody in a divorces actions or positively discriminate in favor of a minority applicant to a university. The point is not just that we like to have someone to hold responsible (blame or praise) when things go awry or splendidly. Is is that we tend to want another human being to have reflected and perhaps agonized over decisions and advice that matter to us. Somehow, in some circumstances, it feels inappropriate, or wrong, to abnegate responsibility and pass it along to a machine, no matter how high-performing.” [1]

Delineating this boundary condition is an important role for us, as professionals. We still have the requisite insight and experience in making these determinations. Unlike, our skilled brethren of the eighteenth and nineteenth century we should work to create and control these machines. There is a conflict of interest here, ours, regarding retaining control, and society’s regarding economic cost. We can continue to act as professionals by being more collaborative with our patients and society, rejecting portions of the grand bargain that make us a monopoly instead of a common good.